Paradigms Shifts in Periodontal Therapy: Implementing Evolving Protocols -Kristy Menage Bernie, RDH, MS, RYT – [email protected] ‐ Scientific paradigms have long been the cornerstone of clinical practice and daily care, yet many of these paradigms are not the “reality.” Emerging sciences have led to key understanding of new methods to prevent and manage periodontal disease, which has necessitated integration and implementation for the progressive clinician. This interactive session will include a review of accelerated periodontal instrumentation protocols and the new gingivitis code, and incorporate recommendations from the AAP Comprehensive Periodontal Therapy document, which will inspire attendees to unconscious competency! Our Opportunities: Gain an understanding of how change occurs and the influence of paradigms versus the realities of our professional protocols and outcomes. Review innovative and evolving technologies and products designed to prevent and treat periodontal diseases. Implement accelerated periodontal instrumentation protocols based on appropriate periodontal coding, as specified in the AAP treatment guidelines. Pre-Session Assessment: What does this seminar title mean to you? What are your expectations?: List 5 ‘changes’ that have impacted the practice of dental hygiene and/or daily life since the beginning of your career: 1. 2. 3. 4. 5. List 5 ‘changes’ in periodontal therapy you have observed and/or incorporated into practice: 1. 2. 3. 4. 5. 1 www.EducationalDesigns.com 2018© Paradigms ‐ in the philosophy of science, a generally accepted model of how ideas relate to one another, forming a conceptual framework within which scientific research is carried out. vs. Reality ‐ everything that actually does or could exist or happen in real life (practice). Current Paradigms in Dentistry/Hygiene? Paradigm Shift: Big Picture! Oral‐Systemic Connection Aesthetic Focus Evidence‐Based Approach Biofilm Focus Minimally Invasive Dentistry Periodontal/Occlusal Connection Patient‐Centered Approach: Regeneration Options Wants vs. Needs; PAIN to GAIN Postural Health ‐ Ergonomics “Green” Dentistry/Dental Hygiene Technology Advances… Paradigm Shift: Assessment/Treatment Protocols Caries Management by Risk Assessment (CAMBRA) Periodontal Risk and Disease Assessment (PRADA) Occlusal Assessment Use of digital technology for assessment and treatment planning Full‐Mouth Disinfection/ Accelerated Periodontal Instrumentation Paradigm Shift: Clinical/Instrumentation Phase Routine use of power scalers Use of lasers Sequencing/value of polishing Professional remineralization strategies Locally applied antimicrobials Pain control options Clinical tongue deplaquing Paradigm Shift: Daily Care Powered plaque control devices Tongue cleaning Toothwhitening Chemotherapeutics The most effective daily oral care regime…is the one patient’s will do! 2 www.EducationalDesigns.com 2018© Minimally Invasive Dentistry www.wcmidentistry.com ‐ World Congress of Minimally Invasive Dentistry Minimally invasive dentistry (MID) is based on a medical model that controls the disease first and then uses minimally invasive techniques to restore the mouth to form, function, and aesthetics. The philosophy behind MID is respecting the health of oral tissue by preventing disease from occurring, or intercepting the disease process with minimal tissue loss. MID allows dentists to become true physicians of the mouth, rather than tooth technicians. MID dentists continue to treat symptoms, but also manage the underlying disease and associated risk factors. MID focuses on the use of highly researched, leading edge, dental materials and products to control disease and to restore hard and soft tissue to the highest standard of form, function and aesthetics. The MID practitioner strives to use the most bio‐mimetic and biocompatible materials currently available. Disease Risk Assessment The two oral diseases that most dental practitioners face every day are caries and periodontal disease. Caries Management by Risk Assessment (CaMBRA): The latest research shows that caries is a pathogenic bacterial infection of the tooth’s natural biofilm and is a multifactorial disease. Measuring the bacterial load, learning the various contributory factors for each patient and assigning a risk level for each patient allows the practitioner to effectively help patients fight caries and the subsequent cavitations. Periodontal Risk and Disease Assessment (PRADA): Periodontal Disease is a host response disease caused by a bacterial infection and is a multifactorial disease that includes a genetic component. Understanding how the body fights this infection and chronic inflammation, the genetic component and implementing new treatment modalities, such as chemical curettage and laser treatment, allow an increase in reattachment of tissue and potential bone regeneration. Biomimetics – use of tissue preserving materials; mimicking of natural life; treatment in which the end result more closely mimics, behaves like or restores natural biology. Regeneration of damaged tissue using molecular information using the body’s own cells and biochemistry as engineering materials. Stages of Change in Practice Protocols… 1. Unconscious Incompetence ‐ The individual neither understands nor knows how to do something, nor recognizes the deficit, nor has a desire to address it. 2. Conscious Incompetence ‐ Though the individual does not understand or know how to do something, he or she does recognize the deficit, without yet addressing it. 3. Conscious Competence ‐ The individual understands or knows how to do something. However, demonstrating the skill or knowledge requires a great deal of consciousness or concentration. 4. Unconscious Competence ‐ The individual has had so much practice with a skill that it becomes "second nature" and can be performed easily (often without concentrating too deeply). He or she may or may not be able teach it to others, depending upon how and when it was learned. 3 www.EducationalDesigns.com 2018© Protocol Considerations: Assessment Phase: Periodontal Risk Factors – American Academy of Periodontology: “Guidelines for the Management of Patients with Periodontal Disease” Journal of Periodontology – September, 2006 Early onset of periodontal diseases (prior Exposed root surfaces to the age of 35 years) A deteriorating risk profile Unresolved inflammation at any site (e.g., Medical or Behavioral Risk Factors/Indicators bleeding upon probing, pus, and/or Smoking/tobacco use redness) Diabetes Pocket depths greater than or equal to 5 Osteoporosis/osteopenia mm Drug‐induced gingival conditions (e.g., Vertical bone defects phenytoins, calcium channel blockers, Radiographic evidence of progressive immunosuppressants, and long‐term bone loss systemic steroids) Progressive tooth mobility Compromised immune system, either Progressive attachment loss acquired or drug induced Anatomic gingival deformities A deteriorating risk profile Visit www.perio.org for self‐assessment of periodontal risk Occulsal Assessment: The Periodontal Connection Aesthetic evaluation Occlusal evaluation Treatment/Instrumentation Phase: Accelerated Periodontal Instrumentation or Full‐Mouth Disinfection Schedule/complete quadrant scaling and root planning within 2 days to 2 weeks Utilize powered scaling instruments with medicament reservoir Laser therapy/treatment Additional therapies as indicated Daily care recommendations 4 www.EducationalDesigns.com 2018© Occlusal Assessments: “Occlusal therapy is an integral part of periodontal therapy. Patients should be informed about the occlusal problem, therapeutic alternatives, potential complications, expected results, and their responsibility in treatment. Consequences of no treatment should be explained. Failure to treat occlusal traumatism appropriately in patients with chronic periodontitis may result in progressive loss of bone and an adverse change in prognosis, and could result in tooth loss. Given this information, patients should then be able to make informed decisions regarding their periodontal therapy.” J Periodontol 2000; 71:873‐ 875. Seven Signs & Symptoms of Occlusal Disease: 1. Pathological occlusal wear and fractures of 6. Vertical bone loss or localized bone teeth/restorations. destruction (secondary to periodontal 2. Cervical dentin hypersensitivity. disease). 3. Tooth hypermobility. 7. Pain and tired facial and masticatory muscles 4. Fremitus. or TMJ pain. 5. Abfractions. Orthodontic Six‐Point Quick Check System: Begin by examining each arch separately and evaluating the following categories: 1. Arch width (molar‐to‐molar transpalatal width of 36 mm is average). 2. Excessive spacing or crowding present. 3. Missing or ankylosed teeth. Then note the relationship between the upper and lower teeth in occlusion. Evaluate the following: 4. Angle’s classification. 5. The amount of overbite and overjet present. 6. Any openbite or crossbite present. Facial Type: Mesocephalic – Jaw bones are in harmony with the rest of the face & with each other; teeth may be malposed & therefore need orthodontic treatment; most common facial type. Brachycephalic – Jaw bones, usually the mandible, are too large in proportion to the face; the face appears short & wide; mandible is usually strong, angular, and possibly prognathic; tendency to brux & grind teeth leading to excessive wear to incisal & occlusal surfaces; when smiling very little tooth structure shows; strong muscles of mastication; from profile perspective